Plan B Ruling: Fox and Family Research Council Seize Opportunity to Spread Misinformation

Plan B One-Step emergency contraceptive on the counter of a CVS pharmacy in New York, April 5, 2013. (Photo: Yana Paskova / The New York Times)Valerie Tarico deconstructs Fox News' and the Family Research Council's misinformation campaign in response to the recent Plan B court ruling allowing girls to obtain the morning after pill without a prescription.

The Fox News response to the recent Plan B ruling provides a graphic example of how the channel uses what it calls "fair and balanced" reporting to create false perceptions. A press release issued by the conservative Family Research Council uses misdirection to attain the same goal. Anyone who wants to understand why the United States is so divided need look no farther than these two pieces of political communication disguised as reporting.

In 2011, the FDA said that Plan B and other brands of levonorgestrel emergency contraception like Next Choice should be available over the counter to all who seek it. But in an unprecedented move, then-Health and Human Services secretary, Kathleen Sebelius, countermanded their recommendation, requiring that females younger than 17 obtain a prescription. On Friday, April 5, Judge Edward R. Korman called those restrictions "arbitrary, capricious and unreasonable" and said that "the secretary's action was politically motivated, scientifically unjustified and contrary to agency precedent." In his ruling making Plan B unrestricted, Korman had a long list of credentialed supporters including the Food and Drug Administration, the American Medical Association, the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics - in other words, all of the most relevant regulatory bodies and professional associations.

FoxNews.com responded with an article titled, "Plan B ruling: Doctors divided over lifting age restrictions on morning-after pill." The article uses a number of well-known propaganda devices that are effective in creating manufactured controversy (aka manufactroversy).

Assertion. The Fox title implies broad disagreement among relevant experts, when in fact opponents are a small minority, many of whom are motivated by religious ideology. A more accurate title would have been "Doctors celebrate lifting age restrictions on morning-after pill." The opening words, "In what has already shown to be a controversial move . . ." assume a controversy, which is psychologically more powerful than attempting to establish one.

Equivocation. Because the article then goes on to talk about the science of medicine, the implication is that this is a scientific controversy. In reality, the science is clear - the overall health and mental health risks associated with possible pregnancy are higher than the risks of emergency contraception - but this rhetorical tactic deftly blurs the line between political controversy and scientific controversy.

Appeal to Authority. The author quotes three physicians, two of whom oppose unrestricted access, leaving the impression that this proportion (two-thirds) represents the level of concern in the medical establishment.

Cognitive bias. Statements from the one interviewee who supports the ruling are sandwiched between the words of those who don't, so that well-known cognitive biases dealing with recall, called primacy effect and recency effect, are both leveraged to create a false impression of risk.

Red Herring. Questions are raised about whether a 13-year-old can fully understand the drug risks. While the same question could be raised about 13-year-olds and pregnancy, this is a red herring. Pregnancy risk and actual pregnancy in 13-year-olds is so infrequent (and so often associated with incest or sexual assault) that teen pregnancy statistics and birth rate generally are reported for girls starting at ages 15 to 19.

Card Stacking. Known side effects of emergency contraception, drawn from a drug insert (for example, nausea), are listed without likelihood information and without providing any information about relative risks of alternatives (for example, the likelihood that unintended pregnancy also may cause nausea).

Appeal to Authority. Quoting directly from their "experts," allows Fox to include speculative claims that would not meet journalistic standards. For example, the list of known side effects is augmented with a speculative list of additional side effects that are not supported by scientific evidence.

Bad Science/Extrapolation/Disinformation/Arguing from Ignorance. Fox experts make statements that contradict both the preponderance of evidence and the preponderance of expert opinion.

In contrast to their speculation and claims:

o No scientific evidence suggests that availability of emergency contraception increases promiscuity or decreases use of more effective contraceptives. In fact, there is evidence to the contrary.

o There is no established pattern of women "overusing" emergency contraception. Again, the evidence points in the opposite direction. Furthermore, it is safe to use such contraceptives more than once. In some European countries a similar formulation has been sold in multipacks as a postcoital contraceptive for women who have sex rarely and don't want to use hormonal contraception all the time.

o Most research on contraceptives that contain levonorgestrel shows no pattern of weight gain beyond that caused by aging alone. Even if a medication were to cause weight gain during ongoing use, there is no reason to think that single or intermittent use would have the same effect.

o The overall rate of ectopic pregnancy in women using levonorgestrel IUD's like the Mirena is lower than the rate in the general population. All contraceptives reduce pregnancy and thus reduce the overall rate of ectopic pregnancy. The misperception of increased risk comes from the fact that hormonal IUDs protect against uterine pregnancy better than they protect against ectopic pregnancy, and so among the rare pregnancies that occur with such contraception (less than 1 in 800 users per year), a higher percent than average are ectopic.

o Although concerns have been raised in the past about a link between hormonal contraception and depression, the best research available finds it no such relationship.it By contrast, there is a clear risk of depression with unwanted pregnancy (or any pregnancy) that is carried to term.

o Benign ovarian cyst enlargement is associated with ongoing use of progestin-based implants, including levonorgestrel implants. This pattern has been described as "common and transient and should not be interpreted as a pathologic ovarian cyst. No further medical interventions are necessary."

o High blood pressure has been reported as a possible side effect in one study of women who used levonorgestrel implants to suppress ovulation for five years continuously. The study was not prospective, meaning it is not known which women had high blood pressure before getting the implant, and there was no comparison group of similar women without the implant.

o Both pregnancy and contraceptive steroids were associated with an increase in gall stones - in cats - in one 1986 study - and levonorgestrel was not. Raising this alarm appears to be more than a stretch.

Bait and Switch

Like Fox, the conservative Family Research Council is concerned primarily that reducing pregnancy risk will increase nonmarital sex, which violates their version of family values. But where Fox printed a long dubious list of side effects, the FRC director Anna Higgins, a nonphysician, took a different tack. She argued that not requiring teens to get prescriptions would increase their sexual transmitted infection risk by circumventing screenings. She also raised the unsubstantiated threat that young girls might be forced to take Plan B without their consent. Instead of providing any evidence for either claim, or for her broader claim that the Plan B ruling "places the health of young girls at risk," the FRC press release simply provided information about STD rates, a classic case of misdirection or "bait and switch."

Increasing anxiety, fear

Propaganda seeks to shift the emotional feelings that attach to a person, policy or other object. In this case, both Fox and the Family Research Council seek to increase fear or anxiety about Plan B. By association, their arguments also increase anxiety about hormonal contraception in general and about the scientific and judicial processes that protect public health. Words like "risk," "danger," "dangerous," "abuse," and "lack of caution," together with lists of scary possibilities serve this end. When "Plan A" fails during intercourse (whether Plan A was abstinence or condoms or another form of contraception), self-care requires clarity and effort. In this situation, doubt or ambivalence often leads to wishful thinking and inaction.

Regulatory and professional bodies like the Food and Drug Administration, the American Medical Association, the American Congress of Obstetricians and Gynecologists, and the American Academy of Pediatrics conduct a complex risk-benefit analysis based on a rigorous review of research. They consider pros, cons and alternatives. Ethical standards require this level of analysis prior to issuing "committee opinions" or recommendations. As a close look at the Fox and FRC approach shows, not all opinions are created equal.

Plan B Ruling: Fox and Family Research Council Seize Opportunity to Spread Misinformation

Plan B One-Step emergency contraceptive on the counter of a CVS pharmacy in New York, April 5, 2013. (Photo: Yana Paskova / The New York Times)Valerie Tarico deconstructs Fox News' and the Family Research Council's misinformation campaign in response to the recent Plan B court ruling allowing girls to obtain the morning after pill without a prescription.

The Fox News response to the recent Plan B ruling provides a graphic example of how the channel uses what it calls "fair and balanced" reporting to create false perceptions. A press release issued by the conservative Family Research Council uses misdirection to attain the same goal. Anyone who wants to understand why the United States is so divided need look no farther than these two pieces of political communication disguised as reporting.

In 2011, the FDA said that Plan B and other brands of levonorgestrel emergency contraception like Next Choice should be available over the counter to all who seek it. But in an unprecedented move, then-Health and Human Services secretary, Kathleen Sebelius, countermanded their recommendation, requiring that females younger than 17 obtain a prescription. On Friday, April 5, Judge Edward R. Korman called those restrictions "arbitrary, capricious and unreasonable" and said that "the secretary's action was politically motivated, scientifically unjustified and contrary to agency precedent." In his ruling making Plan B unrestricted, Korman had a long list of credentialed supporters including the Food and Drug Administration, the American Medical Association, the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics - in other words, all of the most relevant regulatory bodies and professional associations.

FoxNews.com responded with an article titled, "Plan B ruling: Doctors divided over lifting age restrictions on morning-after pill." The article uses a number of well-known propaganda devices that are effective in creating manufactured controversy (aka manufactroversy).

Assertion. The Fox title implies broad disagreement among relevant experts, when in fact opponents are a small minority, many of whom are motivated by religious ideology. A more accurate title would have been "Doctors celebrate lifting age restrictions on morning-after pill." The opening words, "In what has already shown to be a controversial move . . ." assume a controversy, which is psychologically more powerful than attempting to establish one.

Equivocation. Because the article then goes on to talk about the science of medicine, the implication is that this is a scientific controversy. In reality, the science is clear - the overall health and mental health risks associated with possible pregnancy are higher than the risks of emergency contraception - but this rhetorical tactic deftly blurs the line between political controversy and scientific controversy.

Appeal to Authority. The author quotes three physicians, two of whom oppose unrestricted access, leaving the impression that this proportion (two-thirds) represents the level of concern in the medical establishment.

Cognitive bias. Statements from the one interviewee who supports the ruling are sandwiched between the words of those who don't, so that well-known cognitive biases dealing with recall, called primacy effect and recency effect, are both leveraged to create a false impression of risk.

Red Herring. Questions are raised about whether a 13-year-old can fully understand the drug risks. While the same question could be raised about 13-year-olds and pregnancy, this is a red herring. Pregnancy risk and actual pregnancy in 13-year-olds is so infrequent (and so often associated with incest or sexual assault) that teen pregnancy statistics and birth rate generally are reported for girls starting at ages 15 to 19.

Card Stacking. Known side effects of emergency contraception, drawn from a drug insert (for example, nausea), are listed without likelihood information and without providing any information about relative risks of alternatives (for example, the likelihood that unintended pregnancy also may cause nausea).

Appeal to Authority. Quoting directly from their "experts," allows Fox to include speculative claims that would not meet journalistic standards. For example, the list of known side effects is augmented with a speculative list of additional side effects that are not supported by scientific evidence.

Bad Science/Extrapolation/Disinformation/Arguing from Ignorance. Fox experts make statements that contradict both the preponderance of evidence and the preponderance of expert opinion.

In contrast to their speculation and claims:

o No scientific evidence suggests that availability of emergency contraception increases promiscuity or decreases use of more effective contraceptives. In fact, there is evidence to the contrary.

o There is no established pattern of women "overusing" emergency contraception. Again, the evidence points in the opposite direction. Furthermore, it is safe to use such contraceptives more than once. In some European countries a similar formulation has been sold in multipacks as a postcoital contraceptive for women who have sex rarely and don't want to use hormonal contraception all the time.

o Most research on contraceptives that contain levonorgestrel shows no pattern of weight gain beyond that caused by aging alone. Even if a medication were to cause weight gain during ongoing use, there is no reason to think that single or intermittent use would have the same effect.

o The overall rate of ectopic pregnancy in women using levonorgestrel IUD's like the Mirena is lower than the rate in the general population. All contraceptives reduce pregnancy and thus reduce the overall rate of ectopic pregnancy. The misperception of increased risk comes from the fact that hormonal IUDs protect against uterine pregnancy better than they protect against ectopic pregnancy, and so among the rare pregnancies that occur with such contraception (less than 1 in 800 users per year), a higher percent than average are ectopic.

o Although concerns have been raised in the past about a link between hormonal contraception and depression, the best research available finds it no such relationship.it By contrast, there is a clear risk of depression with unwanted pregnancy (or any pregnancy) that is carried to term.

o Benign ovarian cyst enlargement is associated with ongoing use of progestin-based implants, including levonorgestrel implants. This pattern has been described as "common and transient and should not be interpreted as a pathologic ovarian cyst. No further medical interventions are necessary."

o High blood pressure has been reported as a possible side effect in one study of women who used levonorgestrel implants to suppress ovulation for five years continuously. The study was not prospective, meaning it is not known which women had high blood pressure before getting the implant, and there was no comparison group of similar women without the implant.

o Both pregnancy and contraceptive steroids were associated with an increase in gall stones - in cats - in one 1986 study - and levonorgestrel was not. Raising this alarm appears to be more than a stretch.

Bait and Switch

Like Fox, the conservative Family Research Council is concerned primarily that reducing pregnancy risk will increase nonmarital sex, which violates their version of family values. But where Fox printed a long dubious list of side effects, the FRC director Anna Higgins, a nonphysician, took a different tack. She argued that not requiring teens to get prescriptions would increase their sexual transmitted infection risk by circumventing screenings. She also raised the unsubstantiated threat that young girls might be forced to take Plan B without their consent. Instead of providing any evidence for either claim, or for her broader claim that the Plan B ruling "places the health of young girls at risk," the FRC press release simply provided information about STD rates, a classic case of misdirection or "bait and switch."

Increasing anxiety, fear

Propaganda seeks to shift the emotional feelings that attach to a person, policy or other object. In this case, both Fox and the Family Research Council seek to increase fear or anxiety about Plan B. By association, their arguments also increase anxiety about hormonal contraception in general and about the scientific and judicial processes that protect public health. Words like "risk," "danger," "dangerous," "abuse," and "lack of caution," together with lists of scary possibilities serve this end. When "Plan A" fails during intercourse (whether Plan A was abstinence or condoms or another form of contraception), self-care requires clarity and effort. In this situation, doubt or ambivalence often leads to wishful thinking and inaction.

Regulatory and professional bodies like the Food and Drug Administration, the American Medical Association, the American Congress of Obstetricians and Gynecologists, and the American Academy of Pediatrics conduct a complex risk-benefit analysis based on a rigorous review of research. They consider pros, cons and alternatives. Ethical standards require this level of analysis prior to issuing "committee opinions" or recommendations. As a close look at the Fox and FRC approach shows, not all opinions are created equal.